SPONTANEOUS RUPTURE OF SPLEEN DUE TO PLASMODIUM VIVAX MALARIA

Al Owinati B.I., Al Soub H. and Abdul Sattar H.A.,
Department of Medicine, Hamad Medical Corporation, Doha, Qatar

Abstract:

Spontaneous rupture of the spleen is a rare complication of Plasmodium vivax malaria which may be under diagnosed. Recently we encountered such a case in an expatriate a few days after arriving from his country. The presentation was of fever, abdominal pain and vomiting. Computed tomographic scan and ultrasound were not helpful in making an initial diagnosis but the development of hypotension and a significant drop in hemoglobin later pointed to the diagnosis. The rupture was sufficiently severe to necessitate splenectomy. The case is described, treatment options are discussed and pertinent literature is reviewed.

Key Words: Malaria, Splenic rupture, Spontaneous.

Introduction:

Malaria is a major medical problem in many parts of the world. It has become even more important in recent years because of the development of parasite resistance to antimalarial drugs and because of an increase in the amount of international travel. Severe complications related to malaria are seen most frequently in association with Plasmodium falciparum infection (1) The most serious complication related to non-falciparum malaria is spontaneous rupture of the spleen(2). In malarious areas spontaneous rupture of the spleen is rare, presumably because as well as being larger it is also tougher than normal(3). Since 1960 eleven cases of splenic rupture due to malaria have been reported in the English language literature. Probably this does not reflect the actual figure and it suggests that there is significant underreporting and/or underdiagnosis(2). We report this case of spontaneous rupture of the spleen due to Plasmodium vivax malaria in an attempt to increase awareness of this serious and potentially fatal complication.

Case Report:

A 32-year-old Sri Lankan male was admitted to Hamad Medical Corporation on 26 October 2000 with the complaints of fever and chills of seven days duration, epigastric pain and vomiting of two days duration. He had arrived in Qatar seven days prior to admission. There was no history of trauma and his past history was unremarkable except for an attack of malaria one year previously. Physically he was a sick-looking patient with a temperature 37.4OC, blood pressure 90/40 mm Hg, pulse rate 118/minute. Abdominal examination revealed diffuse abdominal tenderness and guarding with absent bowel sounds.

Initial laboratory investigations reported hemoglobin 11.2 gm /dL, white blood cell count 9450/mm3, platelets 44,000/ mm3, creatinine 170 umol/L, blood urea nitrogen 7.6 mmol/L. A blood film was positive for malarial parasites but species identification was not possible on the first specimen. Abdominal ultrasound showed ascites with a normal spleen and liver.

He was given intravenous fluids and intravenous quinine and oral doxycycline. Three hours later he developed more severe abdominal pain, and hypotension. A repeat hemoglobin measurement revealed a marked drop to 6.7 gm/dL. Intra-abdominal bleeding due to a ruptured spleen was suspected. Computerized tomographic ( CT ) scan of the abdomen revealed normal liver and spleen with free fluid in the peritoneal cavity, with a heterogenous collection noted between the stomach and spleen. Peritoneal fluid aspiration yielded frank blood. A blood transfusion was given and emergency abdominal exploration found a large amount of blood in the peritoneal cavity and a slightly enlarged spleen with a long tear at the hilum. Splenectomy was performed.

Pathological examination revealed a spleen weighing 306 g. with grayish and smooth external surface and a bared non-capsulated fragmented area measuring 12 cm x 6 cm. Histologically the sinusoids were infiltrated by immunoblasts, lymphocytes, monocytes, and numerous neutrophils. There were parenchymal hemorrhages and areas of hematomas. Further examination of blood films revealed ring forms and trophozoites of Plasmodium vivax.

Doxycycline was discontinued and the patient completed a course of quinine followed by premaquine. His post-operative hospital course was uneventful and he was discharged ten days later.

Discussion:

Malaria in Qatar is an imported disease. Approximately 300 cases of malaria are reported yearly to the Ministry of Public Health. However to our knowledge this is the first case of spontaneous rupture of the spleen due to malaria seen in our hospital (which is the only hospital providing acute medical care in Qatar) over the last 15 years. This conforms to the international literature, which indicates that this condition is rare(2,4). In reviewing cases of spontaneous rupture of spleen due to malaria, Zingman et al(2) found only 11 cases reported in the English-language literature from 1960 to 1991. This very small figure in spite of the worldwide prevalence of malaria of more than 100 million cases suggests that there may be underreporting and/or underdiagnosis(5). However, malaria remains the most common cause for pathological (so-called spontaneous) rupture of the spleen(4,6) and it is the patient with low or no immunity to malaria who is at risk of rupture(4). This may explain in part the much higher rate of splenic rupture in induced malaria than in naturally acquired infection(2,3,7). In the 11 cases reviewed by Zingman et al(2), all occurred in people with limited or no prior exposure to malaria. Our patient most probably had good immunity against malaria because he came from an endemic area for malaria and had at least one attack of malaria a year prior to his presentation. This finding suggests that people with immunity to malaria are also at risk for spontaneous splenic rupture although the risk may be lower.

Qatar hosts a large expatriate population originating from endemic malarious areas. These usually have a good immunity against malaria at the time of entry but this declines on staying for several years so they will be at risk of splenic rupture if they develop malaria on return home or when they come back to Qatar after leave in their home countries. The malarial species in our patient was Plasmodium vivax, as has been the case in most reported cases of splenic rupture(1,2,3,7 ). Plasmodium. vivax causes rapid splenic enlargement during the acute stage, increasing the risk of rupture(8). The usual cause of spontaneous rupture, whether in malaria or in other conditions is described as a subcapsular hematoma which eventually bursts but there have been reports of malarial cases where the rupture has been described as explosive(9). In acute malaria spleen congestion may occur very rapidly with rupture occurring spontaneously or after minor trauma(8). Therefore it is advisable to avoid vigorous palpation of the spleen during acute malaria in order to avoid splenic rupture.

Sometimes the diagnosis of spontaneous splenic rupture may be difficult because many of the signs and symptoms of rupture may be seen also in patients with severe acute malaria. However the presence of hypotension should point toward rupture of the spleen. Neither ultrasonography nor CT scan were helpful in diagnosing the cause of our patient’s intra-abdominal pathology. It is important to keep a high index of suspicion, making repeated assessment of the patient, coupled with simple laboratory tests. This is especially important in malarious areas where sophisticated costly tests such as CT scan and ultrasound are not available.

Splenic rupture in our patient was treated with splenectomy. Splenectomy has been the standard treatment for splenic rupture ( 2,3) but recently there have been many reports stressing that splenic rupture can be treated conservatively and that splenectomy should be reserved for patients with severe rupture or those with continued or recurrent bleeding(2,4,9,10 ).

Non-operative treatment consists of observation for seven to fourteen days in hospital, strict bed rest, and administration of fluids and blood as needed. Most cases requiring operative intervention can be managed with splenic repair and tamponade(2). The intact spleen plays a central role in the body’s defense against malaria(11) and splenectomized patients are at increased risk for complicated or fatal malaria. Therefore splenic preservation is particularly desirable in the tropics and in patients who intend to go or return to the tropics(4). When splenectomy proves unavoidable, patients should be advised to take antimalarial prophylaxis for life, although compliance is often poor(12).

In conclusion, spontaneous splenic rupture remains a rare complication of malaria, though it may be underrecognized. Because laboratory tests are not diagnostic, keeping a high index of suspicion will allow early diagnosis, and institution of appropriate treatment. Splenic preservation, whenever possible should be attempted. Because of the large number of expatriates in Qatar who originate from endemic malarious areas, physicians working in this country should be aware of this potentially fatal complication.

References:

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3. Hershey FB, Lubitz JM. Spontaneous rupture of the spleen: Case Report and Analysis of 64 Cases. Ann Surg 1948; 127: 40-57.

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5. Wyler DJ. Plasmodium species ( malaria ). In Mandell GL, Douglas RG Jr, Bennett JE,eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, 1990; 2056-66.

6. Smith EB, Custer RP. Rupture of the spleen in infectious mononucleosis: a clinical pathologic report of seven cases. Blood 1946; 1: 317-33.

7. Covell G. Spontaneous rupture of spleen. Trop Dis Bull 1955; 52: 705-23.

8. Facer CA, Rouse D. Spontaneous rupture of spleen due to Plasmodium ovale malaria ( Letter ). Lancet 1991; 338: 896.

9. Clezy JKA, Richens JE. Non-operative management of spontaneously ruptured malarial spleen. Br J Surg 1985; 72: 990.

10. Hunter RA, Kiroff GK. Jamieson GG. The injured spleen: should consideration be given to conservative management? Aust NZJ Surg 1984; 54: 129-35.

11. Garnham PCC. The role of the spleen in protozoal infections with special reference to splenectomy. Acta Trop 1970; 27: 1-14.

12. Hamilton DR, Pikacha D. Ruptured spleen in a malarious area: with emphasis on conservative management in both adults and children. Aust NZJ Surg 1982; 52:310-13.